Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Laparoscopic cholecystectomy reduced complications for patients with acute cholecystitis

ACP J Club. 1998 Jul-Aug;129:7. doi:10.7326/ACPJC-1998-129-1-007


Source Citation

Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. 1998 Jan 31;351:321-5.


Abstract

Question

In patients who have acute or gangrenous cholecystitis, is laparoscopic cholecystectomy as safe and effective as open cholecystectomy?

Design

Randomized controlled trial with up to 2 months of follow-up.

Setting

Hospital in Finland.

Patients

63 patients who were 25 to 88 years of age (mean age 60 y) and had acute cholecystitis (constant right upper abdominal pain that lasted ≥ 24 hours and the presence of 3 of the following criteria: temperature > 37.0 °C, leukocyte count > 10 × 109/L, C-reactive protein level > 10 mg/L, thickening of the gallbladder wall, and edema in the pericholecystic space). Patients not eligible for anesthesia were excluded. Follow-up was complete.

Intervention

All patients received antibiotics (intravenous cefuroxime and metronidazole) and subcutaneous heparin. Patients were allocated to 4-port laparoscopic cholecystectomy with the blunt technique and electrocautery (n = 32) or open cholecystectomy (n = 31) with a subcostal (n = 9) or upper midline (n = 22) incision. When bile duct stones were suspected, intraoperative cholangiography (open cholecystectomy group) or preoperative endoscopic retrograde cholangiography followed by papillotomy and stone extraction (laparoscopic cholecystectomy group) was used.

Main outcome measures

Hospital mortality and morbidity, length of hospital stay, and length of sick leave.

Main results

Analysis was by intention to treat. 10 patients in the laparoscopic cholecystectomy group had preoperative endoscopic retrograde cholangiography, and 1 patient had endoscopic papillotomy and stone extraction. 19 patients in the open cholecystectomy group had intraoperative cholangiography, and 1 patient had stones removed. No deaths or bile duct injuries occurred in either group. More complications occurred in patients who had open cholecystectomy than in those who had laparoscopic cholecystectomy (P ≤ 0.05) (Table). Patients in the laparoscopic cholecystectomy group had a shorter hospital stay than did those in the open cholecystectomy group (median 4 d vs 6 d, P = 0.006). Among the patients who needed sick leave, the length of sick leave was shorter for the 27 patients in the laparoscopic cholecystectomy group than for the 20 patients in the open cholecystectomy group (mean 13.9 d vs 30.1 d, P < 0.001).

Conclusions

Patients who had laparoscopic cholecystectomy had fewer postoperative complications and spent less time in the hospital than did those who underwent open cholecystectomy. No deaths or bile duct injuries occurred in either group.

Source of funding: Helsinki University Central Hospital.

For correspondence: Dr. T. Kiviluoto, Second Department of Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland. FAX 358-9-9-471-4675.


Table. Laparoscopic vs open cholecystecomy in patients with acute cholecystitis*

Outcomes at 1 to 2 mo Laparoscopic Open RRR (95% CI) NNT (CI)
Major complications 0% 23% 100% (—) 5 (3 to 13)
Minor complications 3% 19% 84% (6 to 97) 7 (3 to 116)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

This important study by Kiviluoto and colleagues addresses a topical clinical question. In the past 30 years, urgent surgery for acute cholecystitis has been shown to be as safe as elective cholecystectomy. However, many surgeons have been concerned about the safety of laparoscopic cholecystectomy in the presence of acute inflammation. This study addresses this specific question in a randomized controlled trial. The results show that laparoscopic cholecystectomy for acute cholecystitis is technically feasible and safe as long as a high conversion rate to open cholecystectomy is accepted. Indeed, the morbidity rate was substantially lower in patients who had laparoscopic cholecystectomy than in those who had the open procedure.

This study raises 2 concerns. First, in the laparoscopic group, all operations were done by the investigators, who presumably were fully trained consultants. In contrast, the open cholecystectomies were done by staff surgeons and senior residents. The skill mix may have differed substantially among the operating surgeons, and this may have biased the results in favor of the laparoscopic group.

The second concern is about the management of suspected bile duct stones. The authors used different procedures in the 2 groups (endoscopic retrograde cholangiography with or without papillotomy in the laparoscopic group and operative cholangiography with or without formal stone extraction in the open cholecystectomy group). It may have been more appropriate to use the same procedures in both groups because this difference in treatment may have biased the results.

Overall, however, the results of this study are likely to be reliable and confirm what most laparoscopic surgeons already believe to be true.

John R. Monson, MD
University of HullHull, England, UK